GW1-2021-03318_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford FR WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3270 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if applicable)
FROM TO DUIMETER THICKNESS I MATERIAL
Geological Resources, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WM-0701240 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 ft 2" in sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 fL 8 ft' 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi atioit 0 ft. 0 5 rt. Concrete Pour
Non-Water Supply Well: p
2Monitoring ❑Recovery �$ ft' r 0 ft Dk�011,1 e OCIC
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier i
❑Aquifer Test ❑Stormwater Drainage -
❑Experimental Technology ❑Subsidence Control 1 ft. 8 ft. ;Sand Pour
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grains etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 0.50 rL Grass top soil
01/07/2021 MW-6 0.50 ft. 5 ft. Gray and tan clay
4.Date Well(s)Completed: Well ID# 5 ft. g ft. Gray fine sandy silt
5a.Well Location:
Gates Food Mart 0-00-0000015560
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3 US Highway 158 West, Gatesville, NC
Physical Address,City,and Zip 21.REMARKS
Gates 6979-60-4533 r-_c@Ss+n9
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
36.450011 N 76.699918 W
Signa of Certified Well Contracto Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction.information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 8 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"`+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �'J (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Hand Auger r 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 9 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells'
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county liealth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water,Resources Revised August 2013
1